Multiple regulatory initiatives are targeting the prevention and potential elimination of healthcare-associated infections (HAIs) —an adverse clinical outcome still seen in 1 out of 25 hospitalized patients despite focused performance improvement efforts at the national, state and local levels over the past decade. Heightened attention toward quality healthcare delivery and the transparency of HAI rates through mandated public reporting have notable economic and reputational implications for healthcare organizations within the new pay-for-performance landscape.
While most recognize the urgency for implementing evidence-based, sustainable infection prevention and control (IPC) strategies, hospitals face significant challenges to meeting targeted HAI reduction goals. The complexity of medical care and the continual emergence of multi-drug resistant organisms (MDROs) hinder the implementation of best practices by clinicians aimed at infection reduction, such as removal of invasive monitoring devices and antimicrobial stewardship. The trajectory of HAI reporting requirements has created a data-driven workflow for infection preventionists (IPs), further exacerbating the situation.
The workflow of an IP requires a significant allocation of time to perform surveillance, the process of data collection, aggregation, analysis and reporting. In fact, a survey conducted by the Virginia Department of Health revealed that more than 50 percent of IPs believed they would need to spend at least an additional five hours per week for each type of HAI infection they were required to report to the National Healthcare Safety Network (NHSN).1
Without a comprehensive IPC program that provides access to real-time data delivered in a meaningful and interpretable format, IPs are manually sorting microbiology and laboratory data and reviewing radiology reports, patient progress notes and registration information located in different databases. This process often leads to a reactive approach to managing HAIs and MDROs as opposed to proactive intervention.
High performing IPC programs have helped healthcare organizations reduce rates of certain HAIs by as much as 68 percent. This translates into lives saved with substantial financial impact as industry research suggests these infections cost hospitals about $27,500 per bed per year.
Components of High Performing IPC Programs
The evolution of IPC programs in recent years has moved the responsibility for HAI performance under the quality improvement umbrella for many organizations. With the increasingly complex and expanded value-based reimbursement climate, healthcare organizations are recognizing the relationship between IPC and quality of care delivery.
Because the key to effective infection prevention is early identification, early isolation and early intervention, the need to leverage resources at the highest level possible has become a critical component to effective IPC. Quality departments are realizing that a proactive IPC program is not achievable when an IP’s time is spent manually sifting through data, crunching numbers and generating reports. A high-performing IPC program requires that an IP have time to focus on the following elements to ensure a culture of commitment to infection prevention:
Staff and patient education
Clinicians across the continuum of care must be trained on the latest evidence-based guidelines for effective infection prevention as well as facility-specific protocols and processes. Patients should be educated upon admission of the infection prevention practices that their healthcare workers should be following to prevent the transmission of infection (e.g., handwashing). Patients infected with multi-drug resistant organisms (MDRO) such as Clostridium difficile or communicable diseases should receive specific education on isolation policy and their role in preventing transmission to others.
Evidence-based policies and procedures
Healthcare organizations should have policies and procedures in place based on the most up-to-date industry evidence for infection prevention covering hand hygiene, care of invasive devices, environmental cleaning, MDRO screening and isolation practices. Staff should have easy access to this information as well as a clear understanding of their roles in protecting the patient from communicable diseases through immunizations and work restrictions when they are ill.
A quality-driven IPC program that is proactive in identifying patients at-risk for HAIs and MDROs must leverage real-time disparate data from admission/discharge/transfer, labs, pharmacy, radiology and surgery to increase the likelihood of timely intervention. Surveillance technology with customizable rule alerts streamlines the identification process and equips IPs with the information needed to be successful.
High performing IPC programs establish the endemic rate of sentinel organisms in the facility and monitor for adverse trends to facilitate rapid detection of outbreaks.
Antimicrobial stewardship (AMS)
The development of antibiotic resistance and the ever-increasing list of MDROs have compounded the challenge of controlling the incidence of HAIs. For this reason, IPC programs should include an antimicrobial stewardship component that monitors antimicrobial agent selection by clinicians, tracks patterns of antimicrobial overuse, trends resistance profiles and identifies bug/drug mismatching. Members of the AMS team provide content information to clinicians on best practices for antimicrobial dosing and administration. The data captured with surveillance technology aids the development of MDRO reports and antibiograms to display susceptibility profiles for specific organisms by source and location.
First Steps to Implementing a Quality-Driven IPC Program
A top-down approach must be taken to IPC implementation that aligns with strategic goals of an organization. Executive leadership backing will ensure that resources are properly allocated to the infection prevention team and provide support for the collaborative partnering with other departments, such as environmental services and microbiology, which is essential to the success of the program.
Industry research suggests that 1 to 1.5 full-time IPs is needed per 100 occupied beds to support a quality-driven IPC program. Those numbers should be appropriately supported with administrative, data management and IT resources. IPs are most often infectious disease specialists, microbiologists or nurses who have received training through organizations such as the Society for Healthcare Epidemiology of America (SHEA) and the Association for Professionals in Infection Control and Epidemiology (APIC).
The most effective approach to a quality-driven IPC program will leverage a combination of easily accessible policies and procedures with up-to-date content supported by an advanced infrastructure of surveillance technology. When rule-based, advanced surveillance technology is deployed in tandem with evidence-based HAI prevention strategies, IPs have the ability to efficiently monitor the effect of interventions. For example, a clinical rule can be built into a surveillance system that locates patients at risk upon admission for C. diff by flagging medications often prescribed for treatment of this infection.
High-performing IPC programs are critical to success in today’s pay-for-performance healthcare climate, and the commitment must start with executive leadership to create a culture of patient safety and personal accountability. Consistent feedback provided to key stakeholders on HAI and MDRO outcome metrics and process metrics focused on compliance with evidence-based reduction practices will promote their engagement and enhance collaboration to meet reduction targets.
To be successful in meeting defined performance improvement goals, IPs must be provided with the resources and technology infrastructure that support a proactive approach to HAI and MDRO detection and real-time intervention.
1 Healthcare-Associated Infections 2010 Needs Assessment Report http://www.vdh.virginia.gov/epidemiology/surveillance/hai/documents/pdf/2010_HAI_NeedsAssessmentReport.pdf